Lower back pain is by far the most common ailment suffered by
golfers of all ages. Based on data collected at the Titleist Performance
Institute from over 31,000 golfers, 28.1% of all players deal with lower back
pain after every round. Lower back pain is also the most common complaint seen
among professional golfers on all tours (data suggest over 23% play with
lower back pain). To understand the cause of lower back pain, it requires a
thorough investigation of what I call the “Body-Swing Connection”. Let’s take a
closer look.

The lower back is rarely the original cause of
the pain! It may be the current source of the pain, but
it’s rarely the cause of the pain. More often than not, abnormal motions or
forces coming from adjacent or distant areas of the body force the lower back
to do excessive work until it completely breaks down. In other words, the
lumbar spine is usually the area that is being unnecessarily overworked to the
point of injury. It is basically the over-used and over-abused worker who just
goes it breaks.

In my experience, the lack of mobility seen in the ankles, hips,
thoracic spine and shoulders of many golfers forces the lower back to carry all
of these excessive loads and is the primary cause for most back injuries.

When the lower back finally does break down, you can typically
expect one of the following conditions to occur:

Muscle
Strain or Ligamentous Sprain - A muscle strain or “pulled muscle” as well as an injured
ligament will usually resolve itself in 2-4 weeks with plain old rest and
recovery. However, there can be some residual muscle stiffness, fascial
restrictions, joint fixations or movement alterations that may need to be
addressed using Trigger Point Therapy techniques. Sprains or strains are the
most common form of lower back injury we see. Symptoms may range from a minor
ache to a sharp debilitating pain. Most sprains and strains are localized in
the lower back region, meaning pain does not radiate into the butt or leg. The
chemical inflammation around the injury is usually sore to the touch and the
pain usually subsides with rest.

Disc
Injury - The lumbar
intervertebral disc acts as a spacer between adjacent vertebrae to help absorb
compressive forces and create space for the spinal nerves to exit the spinal
column. Imagine the disc as a jelly filled doughnut. If excessive or abnormal
stressors are placed on the disc, tears can occur. When this happens, the force
of the jelly against that tear can cause a bulge in a portion of the doughnut
leading to a “bulged disc.” In more severe cases, the jelly can actually exit
through the doughnut wall leading to a “ruptured disc.” The discs are also
susceptible to degenerative changes over time. To continue the analogy, imagine
the jelly inside of the doughnut drying up. Any of these disc problems can leave
the spinal nerves vulnerable to irritation or compression resulting in
dysfunction and pain. Most disc pathologies create radiating pain into the
buttocks or the leg (think sciatica) due to the irritation of spinal nerves.
Sitting for prolonged periods of time, bending forward into a slouched
position, or lifting heavy objects can all exacerbate disc symptoms and pain. Hip flexor muscles actually are attached to
the transverse processes of the lumbar spine and the discs! If these hip flexor muscles are stuck in a
shortened position due to over-use and/or excessive shortening due to excessive
sitting then myofascial trigger points occur and cause these muscles to become
stuck in a shortened position. These
shorten muscles will actually cause subluxation of the lumbar vertebra and pull
these disc out. Thus causing bulging
discs! All because the muscles are
dysfunctional. Restore these muscle to
full function and length and over time the bulging disc will return to its
normal position without surgery! How do
you know if you have hip flexors stuck in the shorten position. Sit up, if you find you are slow to
straighten your back, it is not necessarily your back muscles are weak, but
your hip flexors are stuck! Trigger
point therapy is the best and fastest methods of fixing hip flexor muscles
stuck in a shortened position due to trigger points.

Altered
Joint Mechanics or Motor Control - Interestingly, the brain can completely change the lumbar
spine’s ability to move just by changing which muscles are firing or by
altering the sequence of when muscles fire. This can occur in the absence of
any visible injury. These altered motor control or joint mechanics can begin as
a protective mechanism, but can lead to chronic problems over time. Most
experts believe over 80% of all chronic lower back problems begin this way and
are caused by trigger points that result in muscles that cannot lengthen
without intervention from a trigger point therapist..

Degenerative
Arthritis - Just like all
joints, with over-use, abuse, or even lack of use, spinal joints can become
arthritic. Bone spurs and osteophytes act like stalactites and stalagmites
inside a cave closing in on the opening for the spinal nerves. With time, these
bony outgrowths can fuse joints, irritate nerves and create general
inflammation in the area. Stenosis, the narrowing of the canal or cave that
houses the spinal nerves is a very common problem with arthritic changes. Most
arthritic problems in the spine create sharp pain with certain movements. The
resulting inflammation can then cause chronic dull pain over time. Many problems with painful joints that
doctors attribute to degenerative arthritis are actually dysfunctional muscles
that are replete with trigger points in the muscles that act near or on the
joint. Trigger Point therapy often
releases the shorten muscles that stretching only makes worse and the arthritis
pain vanishes!

Bone
Fracture - Stress fractures and
pedicle fractures (spondylosis) are common problems seen in the lumbar spines
of rotational athletes. This occurs due to the rapid extension and rotation of
the spine, causing adjacent vertebrae to collide into each other at their end
range of motion. This action places high forces on the posterior portions of
the vertebrae and can lead to these types of fractures. Injuries of this sort
can lead to deep dull pain and instability in the spine.

So the questions are:

How do I prevent the lower back from getting injured?

How do I treat the injury once it occurs?

Let’s start by talking about prevention. The best way to prevent
lower back injuries in golf is to attack the problem head on with three main
offensives:

Normalize Movement Patterns

Optimize Swing Mechanics

Incorporate Recovery Techniques

Normalize Movement Patterns

The first line of defense against lower back pain is to create
optimal movement patterns in the areas directly above and below the lumbar
spine - the hips and thoracic spine. The golf swing requires great rotational
mobility to develop and transfer energy to the club. That mobility should come
from the joints in the body that are designed to rotate, the hips and the
thoracic spine. If you study the anatomy of the lumbar spine, you will see that
the spinal joints, called facets, are orientated to allow flexion and
extension, not rotation. If the lower back is forced to be a primary rotator
due to a lack of hip and thoracic mobility, it's only a matter of time before
an injury will occur in the lumbar spine. It is important to remember that the
hips and thoracic spine do not operate in isolation. Abnormal motion in the
ankle can cause poor hip motor control. And poor motion in the shoulder can
cause poor thoracic spine motor control. Therefore, we can’t neglect the ankle
or shoulder joints in our assessments.

So in order to unravel the mystery of why someone has lower back
pain, we must first evaluate the movement patterns of all the surrounding
areas. At Indy Myopain Relief Center,
we work with your trainers, golf instructors and evaluate your range of motion
analyses and perpetuating conditions, identifying any of altered movement
patterns and make a true starting evaluation. Once the dysfunction has been
identified, we attack all mobility restrictions first, by treating the trigger
points found in the dysfunctional muscles. Once treated and have restored the stability required to normalize motor
control. When the areas above and below the lumbar spine are functioning
properly, the lumbar spine can gain some much-needed rest. Once normal movement
patterns are optimized, a solid conditioning program is the best form of
prevention. We encourage all players to build a solid base of strength and to
maintain proper mobility in order to keep their lower back healthy for a
lifetime.

Incorporate Recovery Techniques

The first form of preventative action that should be encouraged
is incorporating recovery techniques into a player’s normal after-round
routine. Recovery techniques will help reduce inflammation, restore normative
motor control and repair muscle and joint damage sustained during the round.
Basic forms of recovery include the following:

Hot and cold therapy - This includes ice packs, cold plunges,
heating pads, hot packs, hot tubs, sauna, steam rooms, etc. All of these
methods can help make a difference after a round. Experimentation with
alternative methods may be necessary to find the best combination for each
player. I find that most muscle
pain responds to moist heat

Massage - This is one of the best ways to reduce soreness, flush
inflammation and revitalize the soft tissue.

Nutritional Support - There are many nutrients that can help
reduce soreness, repair muscle damage and control inflammation. After four or
five hours of playing golf, the body is in a slightly depleted and catabolic
(tissue destructive) state. At this time, it is critical to eat the right type
of foods to help facilitate recovery of muscles, tendons and ligaments. A
player can feel dramatically better the next day by simply adding a post round
recovery shake or incorporating proper dietary recommendations. We encourage
players to immediately replenish their carbohydrates to help reduce soreness
and to add some protein to help repair muscle and tendon damage. Drinking
plenty of water is also a great recovery technique. Dehydration after a round
can lead to next day soreness and muscle fatigue.

Sleep - One of the most important recovery techniques that I
can’t stress enough is a minimum of eight hours of sleep. This is when the body
repairs and rebuilds. Without that necessary sleep, most players will
wake up sore.

Recovery Exercise - Many exercises can help aid recovery.
Stretching is a great example of an exercise that can help re-establish normal
motor control after a round.

Now let’s shift our attention to some actions that can be taken
if, unfortunately, you already have a lower back injury. The major types of injuries and options available for treatment. Remember, the
preventative actions discussed above should also be incorporated into the
treatments below.

Muscle Strains

Treatment of muscle strains should focus on controlling the
initial inflammation and restoring proper muscle, joint and ligamentous
function. Typical treatment protocols include some combination of the
following:

Manual Therapy – Trigger Point Therapy, Extracorporeal
Shock Wave Therapy, Myofascial Acoustic Wave Therapy, Extracorporeal Pulse
Activation Therapy, Myofascial Release, Massage, Chiropractic physical therapy,
osteopathy, and other manual therapy techniques can be extremely effective in
reducing the recovery time for muscle strains and ligamentous sprains. These
options help promote muscle lengthening and proper blood flow in the lower back
(to help with healing), loosen tight lower back muscles, maintain proper joint
mechanics, and aid in the release of endorphins, the body’s natural
painkillers. All of these things promote accelerated healing in the lower back.

Cold Therapy (Cryotherapy) - The application of cold packs over the
injured area can dramatically help numb the tissues and may relieve muscle
spasms or associated inflammation. Cold can be applied using an ice or gel cold
pack, cold plunge pools, cryotherapy chambers (which use liquid nitrogen to
cool the room) or topical sprays (such as ethyl chloride) that cool by
evaporation. Do not apply cold to tissues with an already reduced blood supply
(for example, when the arteries are narrowed by peripheral arterial disease).

Electrical Stimulation in combination with
Trigger Point Therapy -Electrical
stimulation via electrodes placed on the skin has been used to help speed
recovery for years. Electrical stimulation with Trigger Point Therapy can
increase nervous system activity and stimulate fluid circulation resulting in
reduced inflammation. One form of electrical stimulation called transcutaneous
electrical nerve stimulation (TENS) uses a low current that will cause muscles
to contract slightly. When TENS is coupled with Trigger Point Therapy results
in trigger points releasing faster and more completely. The device produces a
tingling sensation but is not painful.

Acupuncture - This involves treating various points on the
body using several methods such as the insertion of thin needles, application
of heat, applying pressure or laser light therapy. Traditional acupuncture
involves needle insertion, moxibustion (burning of a Chinese herb) and cupping
therapy. This is a fundamental component of traditional Chinese Medicine that
has been used for over 5,000 years. It is further believed the stimulation of
specific acupuncture points corrects imbalances in the flow of Qi (chi) through
channels known as meridians. By balancing the body’s qi, healing is
accelerated. Acupuncture should be done by a certified acupuncturist and with
sterile needles.

Dry Needling – Is the practice first introduced by doctors
Janet Travell and David Simons. Dry
needling first begins by locating taut bands of muscles and then precisely
locating the trigger point nodule within the taut band, then accurately and
precisely inserting a dry, sterile needle into it repeatedly until the taut
band relaxes. The skill that is lacking
in most dry needle therapists is the ability to locate the taut bands. This practice is best done by Trigger Point
Therapists, Physical Therapists with advanced training and others. Physicians that inject muscles with lidocaine
and cortisone are injecting muscles and on rare occasion locate the trigger
point. With a skilled therapist, dry needling is highly effective and almost
essential when tiny muscles in small spaces develop trigger points such as the
front of the neck and pelvic floor muscles. However, dry needling performed by a skilled therapist is a highly
effective treatment. Most trigger points
can be released using manual and acoustic compression therapy and is not
invasive. Indy Myopain Relieve Center
does not perform dry needling but would refer our clients to a Clinic in
Bethesda, MD.

Rest & Recovery - Often, muscle strains just need a few days
of TLC. However, we do not mean someone should remain 100% bedridden. Reduction
of workload, not lifting heavy objects, time off from strenuous activities,
improvement in workplace ergonomics and modification of poor sleeping habits
can usually do the trick. The body has an amazing ability to heal sprains and
strains as long as you stop aggravating it. Just remember, light activities
such as walking can be very beneficial in accelerating the recovery process.

Anti-inflammatory Medication - Local inflammation that may exacerbate
pain can be reduced with the aid of anti-inflammatory medication such as
ibuprofen or NSAIDs. Just remember, these medications only reduce the
inflammation and do not fix any potential muscle or ligamentous damage that may
lie below the inflammation. Recent studies are showing that NSAIDs, Cortisone
and narcotics actually inhibit nitric oxide and other methods the body uses to
mobilize you body’s own repair mechanisms and certainly should not be used
following trigger point therapy. Be
warned, chronic use of NSAIDs can become part of the problem and not part of
the solution.

Muscle Relaxants - If muscle spasms are present (which are
often associated with muscular strains) these drugs may relieve some of the
pain associated with the muscle spasms or help you sleep at night but they too
are reported to inhibit the body’s ability to heal itself.

Do not wait for the
pain to subside, contact Indy Myopain
Relief Center right away. Our therapies
are most effective when the pain is at its crescendo. We can often relieve the pain in minutes and
teach you how to fix your own pain. Once
the pain has subsided, we must investigate why the injury occurred in the first
place. In other words, there is usually some underlying altered movement
pattern that caused the sprain or strain to happen. We go back to our range of
motion screens to make sure the original cause of the problem has been
addressed as well as the resulting sprain and strain.

Disc Injuries (Non-Surgical Options)

As we discussed earlier, the intervertebral disc resembles a
jelly filled doughnut. All of the treatment options below focus on reducing the
irritation or compression to the spinal nerves created by the abnormal
displacement of the jelly. Here are the most common options:

Conservative Rehabilitation - The first line of treatment should
always involve a 6 to 12 week trial of trigger point therapy and/or
Extracorporeal Shock Wave Therapy. The goals of these types of treatment are
to:

Reduce the inflammation

Restore normal stability, motor control and motion in
the lumbar spine

Improve mobility in the surrounding joints (hips and
thoracic spine)

Educate the patient on techniques to prevent further
episodes such as ergonomics, sleeping positions, proper lifting and carrying
techniques, recovery options, etc.

Supply the patient with an exercise routine to prevent
re-injury

Most patients will feel some sort of relief right away. Many
successful rehabilitation programs include a combination of many conservative
techniques.

Epidural Injections or Medrol Dose Pack –The anti-inflammatory of cortisone
actually inhibits healing but is still very popular with physicians. Physicians will say that approximately 50% of
the time, an epidural steroid injection will give pain relief that may last
from one week up to one year. Most physiatrists recommend a maximum of three
epidural injections per calendar year (at least two weeks apart). Recent studies have shown better results with
just the pain reliever injection and not cortisone.